JSAN 2014;1:7-12. Available online at www.jsan.org.np Journal of Society of Anesthesiologists of Nepal Original Article Study of factors associated with waiting time for patients undergoing emergency surgery in a tertiary care centre in Nepal. Subhash Prasad Acharya, Dinesh Dharel, Smrity Upadhyaya, Nabin Khanal, Sandesh Dahal, Sumit Dahal, Karmapath Aryal Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu, Nepal. Abstract Background: Emergency surgeries throughout the world are demanding earlier surgical times. In a developing country like Nepal this cannot be possible because of lot of factors. So we planned to study such factors that could interplay and increase the waiting time for emergency surgeries. Methods: A prospective observational study was conducted over 45 days and all patients diagnosed with general surgical and orthopedic emergencies were followed till they were operated. Results: Out of 1211 patients presenting to emergency department, 92 required emergency surgery. The mean age was 29.72 year and 76.1% of the patients were male. The mean time from presentation to the emergency department to the first surgical consultation was 170 minutes, from surgical consultation to decision of surgery was 28 minutes, from decision of surgery to transfer to operating room was 426 minutes, from arrival in operating room to anesthesia consultation was 18 minutes, and from anesthesia consultation to start of surgical incision was 75 minutes. The total average waiting time from arrival at emergency department to the start of surgery was 717 minutes. The factors were, viz., pre-occupancy of theatre (59.8%), special procedures/intervention required prior to surgery (23.9%), arrangement of logistics/finances by patient family (13%), arrangement of blood products (10.9%), consultations (9.8%), delay in giving consent by patients/family (5.4%), delay in arrangement of supplies (9.8%), and shift change of nursing staff (3.3%). Conclusion: This study shows that various preventable factors increases waiting times for emergency surgeries that should be minimized so that waiting times can be reduced. Keywords: Delaying Factors; Emergency surgery; waiting times. Article History © Authors retain copyright and grant the journal right of Received 3rd January 2014 first publication with the work simultaneously licensed Accepted 27th February 2014 under a Creative Commons Attribution License that Published on print 1st March 2014 allows others to share the work with an Published online 24th December 2014 acknowledgement of the work's authorship and initial publication in this journal. How to cite this article: Acharya SP, Dharel D, Upadhyaya S, Khanal N, Dahal S, Dahal S, et al. Study of factors associated with waiting time for patients undergoing emergency surgery in a tertiary care centre in Nepal. JSAN 2014;1:7-12. Introduction The accessibility to prompt and appropriate health care is one of the components that reflect the efficiency of the health care delivery system in any institution. The emotional and psychological trauma following Corresponding Author: Subhash P Acharya, MD, FACC, FCCP Intensivist and Clinical Coordinator, TUTH ICU Lecturer, Department of Anaesthesiology, Institute of Medicine (IOM) Email: [email protected] Phone: 977-9851147242 7 JSAN 2014;1:7-12. emergency admission can increase significantly if surgical intervention is unduly delayed. Although some surgical emergencies can and often should be dealt with some hours or even days after admission, there remains a group of conditions for which surgery should be available within hours or even minutes of arrival. In these patients, a delay could mean loss of life or permanent disability. In practice the timing of operative intervention is influenced by many factors including clinical diagnosis, investigations required, complications of disease, logistics required, workload of physicians, and availability of operation theatre. Emergency surgeries performed in a handful of tertiary care centers in Nepal comprise a major segment of emergency surgeries performed throughout the country. Tribhuvan University Teaching Hospital (TUTH), one of such tertiary care center has the largest number of medical and surgical specialties among the hospitals in Nepal. The services provided range from basic medical and surgical problems to open heart surgery and renal transplant. Total number of emergency surgeries performed at TUTH in the year 2066 was 2069 compared to 3607 elective surgeries in the same period. Thus, the increasing demand for hospital services has led to longer waiting times, crowded conditions and highly variable care and outcomes as well as dissatisfaction among the patients. Thus this study was conducted to identify the waiting time for patient undergoing emergency surgeries so as to identify various factors governing the waiting time. Methods A prospective observational study was conducted from 4th January 2011 to 20th February 2011 over a period of 45 days. All patients attending emergency department and diagnosed to have a surgical emergency were included in the study. The patient’s details and required data were collected in a preformed data collection form, which was prepared after the studying past records of emergency surgeries. In depth interview guidelines was prepared separately for the patient/visitors and the concerned health care provider in cases where more information was required. All emergency surgeries performed on inpatients or outpatients, but not through the emergency department, were excluded. Those patients whose surgery was cancelled or postponed due to various reasons after shifting to Operation Theatre (OT) were also excluded. Emergency surgeries performed by the departments other than General Surgery and Orthopedics were excluded to maintain uniformity and to avoid various bias. The waiting time was defined as the time interval between the times of presentation of patient at Emergency department to the time of start of surgery. To identify various factors, the waiting time was divided into five intervals as follows: From presentation to the emergency department to the first surgical consultation From surgical consultation to decision of surgery From decision of surgery to transfer to operation theatre From arrival in theatre to anesthetic consultation From anesthetic consultation to the start of surgical incision. The factors contributing to each of the interval were identified & analyzed under following headings: Patient factors: Age, sex, address, duration since first complain, logistic arrangement, time of consent. Disease factors: Diagnosis, co-morbidities affecting patient’s fitness for surgery, investigations required, surgery required, Special intervention including anesthetic procedures prior to surgery. Hospital factors: Consultations from other departments, number of emergency surgeries performed on the same day, manpower available, availability of OT resources. The data was entered in the database created in SPSS version 17 for Windows. Before analysis, all sets of data were rechecked, and after correcting entry error, data was transformed into variables and analyzed. RESULTS During the study period of 48 days, total number of 92 cases requiring emergency surgery in main operating room was studied. Out of these cases, the age of patient ranged from 7 to 84 years with a mean age of 29.72 years. Seventy patients (76.1 %) were male and 22 (23.9%) patients were female. Out of the total cases, 86.9% cases were cases of General surgery, 12% of Orthopedics and the remaining 1.1% was of Cardio Thoracic and Vascular Surgery (CTVS) cases. Figure 1. Distribution of ER Surgical Cases 8 JSAN 2014;1:7-12. 12%1.10% 86.90% General Surgery Orthopedics CTVS Consultation with another department other than the concerned surgical department was required in only 23.9% of patients. The departments consulted were Medicine: 9.8%, Orthopedics: 5.4%, General surgery: 2.2%, CTVS: 4.3%, Ophthalmology: 1.1%, Anesthesiology: 2.2%, Ear Nose Throat & Head Neck Surgery (ENT- HNS): 1.1%, Dental: 1.1%. But 76.1% patients did not required consultation from other departments. Figure 2: Consultation with other departments 1.10% 2.20% 1.10% 9.80% 1.10% 4.30% 2.20% 5.40% Medicine Orthopedics General surgery CTVS Ophthalmology ENT Anesthesiology Dental Additional co-morbidities were present in 8.7% patients of the patients and special investigations (including CT Scan, MRIs) were done in 9.8% of patients. Once in the OT, the anesthesia provided were: General Anesthesia (GA): 46.7%, Sub-arachnoid Block (SAB): 41.3%, Local Anesthesia (LA): 1.1% and Regional Anesthesia (excluding SAB) (RA): 10.9%. Procedures in anesthesia before the surgical procedure including arterial line insertion, central venous catheter insertion and epidural catheter insertion that also contributed to some delay occurred in 23.9% of cases. This was also considered as a delay as this also contributed as the time of incision was taken as the start of surgery. Figure 3. Forms of Anesthesia applied 1% 11% 47% 41% GA SAB RA LA The mean time from presentation to the emergency department to the first surgical consultation (Interval 1) was 170 minutes. The mean time from surgical consultation to decision of surgery (Interval 2) was 28 minutes. The mean time from decision of surgery to transfer to operation theatre (Interval 3) was 426 minutes. The mean time from arrival in theatre to anesthetic consultation (Interval 4) was 18 minutes. The mean time from anesthetic consultation